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Avon Partnership Occupational Health Service PRIVATE & CONFIDENTIAL Occupational Health Referral Request Form Please complete fully in BLOCK CAPITALS OR UPPER CASE TYPE. Incomplete referrals will

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How to Fill Out an Occupational Health Referral Request:

1. Begin by gathering the necessary information. This may include the employee's name, department, job title, and specific reasons for the referral. It is essential to provide as much detail as possible to ensure appropriate care.
2. Fill out the date and contact information section. Include the requester's name, designation, and contact details. It is crucial to provide accurate contact information to facilitate any necessary follow-up.
3. Indicate the employee's medical history and any relevant pre-existing conditions. This information helps occupational health professionals better understand the employee's overall health and any potential risks or concerns.
4. Describe the nature of the injury or illness that requires attention. Clearly explain the symptoms, when they started, and any potential causes. This information will aid the occupational health professionals in diagnosing and treating the employee's condition.
5. Specify any specific assessments or tests that are required. If there are any specific tests or evaluations that are necessary for the employee's referral, indicate them clearly.
6. Provide any additional information or special considerations that may be relevant. This could include any accommodations or restrictions that the employee requires or any other pertinent details.
7. Ensure that the referral request is signed and dated by the appropriate person. This could be the employee's supervisor, human resources representative, or any other designated individual as required by company protocol.

Who Needs an Occupational Health Referral Request:

1. Employees who have experienced work-related injuries or illnesses may require an occupational health referral request. This includes cases such as accidents, chemical exposure, or physical strain from work activities.
2. Individuals who are experiencing symptoms that may be related to their workplace environment should also seek an occupational health referral. This could include respiratory issues from exposure to hazardous substances or repetitive motion injuries.
3. Job applicants or employees who need specific medical exams or assessments as part of their job requirements may also require an occupational health referral request. This could include fitness-to-work examinations, specialized screenings, or physical assessments.

In conclusion, filling out an occupational health referral request involves gathering relevant information, providing a detailed description of the condition, specifying any necessary tests or evaluations, and signing the request. Anyone who has experienced a work-related injury or illness, requires occupational health assessments, or needs medical exams for job requirements may need an occupational health referral request.

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What is occupational health referral request?

Occupational health referral request is a formal request made to refer an employee to occupational health services for a comprehensive evaluation of their health in relation to their job duties.

Who is required to file occupational health referral request?

Employers are typically required to file occupational health referral requests on behalf of their employees.

How to fill out occupational health referral request?

To fill out an occupational health referral request, the employer must provide relevant information about the employee's job duties, any health concerns, and the reason for the referral.

What is the purpose of occupational health referral request?

The purpose of an occupational health referral request is to ensure that employees are healthy and fit to perform their job duties safely.

What information must be reported on occupational health referral request?

The occupational health referral request must include the employee’s personal information, job duties, any health concerns, and the reason for the referral.